Workshop overview
The International Institute of Quality Accreditation & Rankings (IIQA) presents a practical and experience-driven NABH Accreditation Workshop designed to help hospitals and healthcare organisations understand, prepare for and strengthen their NABH accreditation journey. The workshop focuses on the practical implementation of NABH standards, quality systems, patient safety practices, documentation, evidence management, process implementation, internal monitoring, gap identification, corrective actions and assessment-visit readiness. Participants will gain a structured understanding of how to move from initial preparation to systematic implementation and sustained compliance with applicable NABH requirements. UNDERSTAND → PREPARE → IMPLEMENT → DOCUMENT → ASSESS → IMPROVE
What will the workshop cover?
01NABH Framework & Accreditation Process
- Understanding NABH accreditation
- Purpose and scope of accreditation
- Understanding applicable standards
- Accreditation preparation stages
- Organisational responsibilities
- Accreditation planning
- Implementation approach
- Assessment process
- Post-assessment improvement
02NABH Standards Interpretation & Requirement Mapping
- Understanding standards and objective elements
- Interpreting requirements
- Identifying department-wise applicability
- Mapping requirements to hospital processes
- Identifying responsible departments
- Defining implementation responsibilities
- Establishing compliance monitoring mechanisms
03NABH Preparation & Gap Assessment
- Baseline assessment
- Current-status evaluation
- Department-wise gap identification
- Documentation gaps
- Implementation gaps
- Evidence gaps
- Infrastructure and resource gaps
- Prioritisation of gaps
- Gap closure planning
04Documentation & SOP Preparation
- Quality documentation framework
- Policies
- Manuals
- Standard Operating Procedures
- Guidelines
- Protocols
- Forms and formats
- Registers and records
- Document control
- Version control
- Approval and review mechanisms
- Department-wise documentation
05Implementation of NABH Standards
- Translating standards into practice
- Assigning responsibilities
- Department-level implementation
- Staff awareness and training
- Process standardisation
- Monitoring implementation
- Record generation
- Evidence collection
- Interdepartmental coordination
- Management review
06Quality & Patient Safety Systems
- Quality improvement programme
- Patient safety programme
- Quality indicators
- Key performance monitoring
- Incident reporting
- Near-miss reporting
- Risk identification
- Root Cause Analysis
- Corrective and Preventive Action
- Clinical audit
- Continuous improvement
07Data, Records & Evidence Management
- Identification of required evidence
- Department-wise record management
- Evidence mapping
- Data collection
- Data validation
- Record completeness
- Evidence traceability
- Maintaining current records
- Monitoring compliance
- Organising assessment evidence
08Internal Assessment & Compliance Monitoring
- Internal audit approach
- Department-wise compliance assessment
- Tracer methodology
- Identifying non-conformities
- Document verification
- Record verification
- Staff interaction and awareness
- Corrective action tracking
- Reassessment of closed gaps
09Corrective Action & Gap Closure
- Gap classification
- Root-cause identification
- Corrective action planning
- Responsibility allocation
- Timeline development
- Evidence of corrective action
- Effectiveness monitoring
- Closure verification
- Preventing recurrence
10Assessment Visit Readiness
- Assessment preparation
- Department readiness
- Staff awareness
- Document availability
- Record readiness
- Evidence organisation
- Facility readiness
- Patient-care process readiness
- Tracer preparedness
- Interaction with assessors
- Handling assessment observations
- Mock assessment approach
11Leadership, Governance & Staff Involvement
- Role of hospital leadership
- Quality leadership
- Departmental responsibilities
- Quality committee functioning
- Staff awareness
- Training and competency
- Multidisciplinary participation
- Monitoring compliance
- Management review
- Accountability and follow-up
12NABH Action Plan & Sustainable Implementation
- Consolidating identified gaps
- Prioritising action areas
- Responsibility allocation
- Timeline development
- Department-wise action plans
- Monitoring mechanisms
- Review of implementation
- Effectiveness evaluation
- Sustaining compliance
- Continuous improvement roadmap
What will you gain?
- Participants will gain practical understanding of:
- NABH accreditation requirements
- NABH accreditation preparation
- Applicable standards interpretation
- Gap assessment
- Accreditation planning
- Documentation preparation
- SOP and policy development
- Department-wise implementation
- Quality and patient safety systems
- Data and evidence management
- Internal assessment
- Corrective and preventive actions
- Quality indicators
- Staff awareness and training
- Assessment-visit preparedness
- Mock assessment approach
- Continuous improvement
- Sustainable NABH implementation FROM STANDARDS → PREPARATION → IMPLEMENTATION → EVIDENCE → ASSESSMENT → CONTINUOUS IMPROVEMENT
Who can participate?
Hospital Leadership
Chairpersons • Directors • CEOs • Medical Superintendents • Hospital
Administrators • Senior Management
Quality & Accreditation Teams
Quality Managers • NABH Coordinators • Accreditation Teams • Quality
Assurance Teams • Patient Safety Teams
Clinical Teams
Doctors • Nursing Professionals • Department Heads • Clinical Coordinators
Infection Control Professionals • Pharmacy Professionals • Laboratory
Professionals
Administrative & Support Teams
HR • Administration • Medical Records • Biomedical Engineering • Facility
Management • Housekeeping • CSSD • Dietary Services • Security • IT
DESIGNED FOR
Hospitals • Medical Colleges • Multispecialty Hospitals • Specialty Hospitals
Healthcare Organisations • NABH Applicant Hospitals • NABH Accredited
HospitalsThe original workshop similarly separates participants into leadership, quality
teams and functional teams before identifying the intended institutional
audience.